Project Summary/Abstract Major surgery in frail elders is frequently ineffective. High-risk surgery in frail patients often leads to death, severe complications, and poor quality of life. Less risky operations may be ineffective when patients with limited life-expectancy die before experiencing harm from the surgical condition. Our overall goal is to improve surgical care for frail older adults by better individualizing treatment to patients' overall condition and goals. Currently, surgeons lack the tools to make careful decisions about surgery in frail older patients. Creation of a comprehensive, individualized surgical evaluation in this population should include a realistic estimate of surgical risks, an understanding of overall prognosis based on each patient's burden of medical illness, access to robust, supported non-operative options, and effective communication algorithms. To reinforce thoughtful decision-making, surgeons also need feedback about the quality of life of frail elders after they have left the hospital. The object of this project is to advance our overall goal by developing and refining tools for reducing ineffective surgery that focus on individualized surgical risk assessment, prognostication, effective communication strategies, robust nonoperative options, and surgeon performance feedback of patient-reported outcomes. To achieve this objective, we have 3 aims: 1) to use direct observation and in-depth interviews in a diverse surgery clinic settings to determine how to tailor tools are that are relevant, feasible, and acceptable in different types of practice settings, 2) to develop an ethnographically tailored practice-change toolkit for surgeons to support appropriate use of surgery in frail older adults, and 3) to gather input from clinicians and national experts in surgical quality on how to refine and eventually test acceptable and scalable interventions to stop ineffective surgery. Candidate elements for evidence-based toolkit include a patient assessment tool that includes an individualized, procedure-specific surgical risk calculator, validated prognostic indices, communication algorithms, and elements that actively support non-surgical care pathways early in the surgical evaluation. Finally, we will develop methods to provide feedback to surgeons about longitudinal patient-reported outcomes. This innovative project is the first study to develop practice change strategies to stop ineffective surgery. Subsequent testing and dissemination of these strategies will revolutionize surgical care so that frail elderly patients can achieve their treatment goals ? with or without surgery.